Assistant Professor Washington University Orthopaedics Saint Louis, Missouri, United States
Case Diagnosis: Our case involves spinal cord trauma with right upper extremity (RUE) symptoms resolving in 5 days and right lower extremity (RLE) symptoms resolving in 6 weeks, leading to a gray diagnostic area between prolonged transient hemiplegia and incomplete spinal cord injury.
Case Description: An otherwise healthy 21-year-old hockey player sustained a cervical whiplash injury during competition after being checked and falling backwards onto the ice. Initial assessment revealed right-sided hemiparesis and sensory abnormalities. MRI of the brain/cervical spine and CT angiogram were unremarkable. Right upper extremity symptoms resolved in 5 days. At 6 weeks, she regained RLE strength with ongoing sensory deficits. Repeat imaging was unremarkable. At 18 weeks sensory symptoms resolved with the exception of mildly decreased LE proprioception. The athlete was cleared to return to non-contact drills.
Discussions: Transient quadriplegia and/or hemiplegia (“cervical cord neuropraxia (CCN)”) following cervical spine trauma typically resolves in 48 hours while incomplete spinal cord injury without radiographic abnormality (SCIWORA) is more likely to present with persistent symptoms. This case includes features of both diagnoses making management challenging as return to play guidelines are diagnosis specific. Return to play guidelines after CCN or SCIWORA symptom resolution are controversial, with current risk stratification ranging from a single episode indicating clearance to more than two episodes indicating absolute contraindication. Additionally, the concurrent presence of other spinal abnormalities can significantly alter the patient’s final recommendation.
Conclusions: Sports medicine physicians must overcome tremendous extrinsic pressure from athletes/families/athletic staff in order to make decisions for the best of the patient. Further research is needed to develop well-defined guidelines for SCIWORA and CCN return to play decisions.